Massachusetts Department of Developmental Services Risk Management 

Subject:      Constipation

What is it?   

Constipation occurs when an individual has difficulty passing stools.  The stools are hard, dry, and often look like marbles.  Individuals  who experience constipation have infrequent bowel movements, pass hard stools or strain during bowel movements.The frequency of bowel movements differs from person to person.   Bowel movements are considered normal as long as the feces is soft, normal sized and is passed easily out of the bowel.  
What risk does it present?  
Unmanaged constipation can cause pain, discomfort, and lead to increased hospitalizations and invasive testing.  Severe constipation may cause fecal impaction, bowel obstruction, bowel perforation, and electrolyte disturbances. This can lead to surgery and increased risk of death.  Chronic constipation can increase an individuals risk for colon and rectal cancer due to the build up of toxins and harmful bacteria in the colon.
Who is at risk?
  
Individuals with:
•	Neuromuscular degenerative disorders
•	Spinal chord injury or birth defects such as spina bifida	
•	Muscle weakness
•	Decreased mobility
•	Diets that do not contain enough fiber and fluids
•	Poor swallowing skills with aspiration risk 
•	Inadequate or inconvenient access to the bathroom
•	Immobility and poor body alignment 
•	Medications that slow down gastric motility or draw too much fluid from the GI tract
•	Hemorrhoids or other conditions that make bowel elimination painful
•	Repression of the urge to defecate due to psychiatric issues
•	History of frequent bowel stimulant use leading to decreased bowel reactivity
•	History of constipation
•	Pica

Signs and symptoms of constipation include:
•	Infrequent or irregular bowel movements (less than 3 bowel movements per week with lumpy or hard stool that is difficult to pass)
•	Bloating, intestinal gas, abdominal distention, abdominal discomfort, or the feeling of incomplete bowel evacuation
•	Indigestion
•	Straining or grunting while passing stool
•	Nausea or vomiting
•	Decreased appetite – refusing to eat or drink
•	Blood in stool
•	Painful bowel movements
Signs and symptoms that require immediate emergent attention:
•	Hard protruding stomach 
•	Vomiting that smells like stool with or without a fever
•	Runny liquid stools after several days of passing small hard stool
What are the guidelines to minimize risk?
•	Dietary consult 
•	Increase fiber (up to 20-5 grams per day) 
High fiber foods include – beans, whole grains, fresh fruits, vegetables
•	Limit low-fiber foods. Foods that are high in fat and sugar and those that tend to be low in fiber content, such as ice cream, cheese and processed foods, may cause or aggravate constipation.
•	Exercise
•	Fluids – water, juices, prune juice
•	Give enough time to move bowels on toilet
•	Establish a toileting routine if needed
•	A positioning schedule for non-mobile individuals with  time in an upright position (Physical Therapist consultation may be needed)
•	Monitor bowel movements  document size, color, texture
•	Determine the need for laxative use
•	Review medications that may cause constipation – diuretics (lasix), opiods, iron supplements, antacids, calcium supplements, anti-diarrheal agents, 
•	Monitor PRN use of laxatives (If ordered)
•	Consult with the physician to determine the need for an individualized bowel protocol

An individualized protocol is a proactive approach to treating symptoms of constipation.  It is a physician order that consists of:
•	Diagnosis
•	Symptoms of constipation
•	When to give PRN medications
•	Any individualized special instructions
•	How to document
•	Instructions that identify when to report or call physician or program nurse
Bowel medications:
Stimulants cause rhythmic contractions in the 
intestines    	Corr Correctol, Dulcolax, Senna	
Lubricants enable stool to move through the colon easier. 
	Mineral oil and fleets
	
Stool softeners moisten the stool and help prevent dehydration.
	Colace 
	
Fiber supplements, or bulk laxatives are generally considered the safest of the laxatives.  Need to take with 8 ounces of water and follow through with another 8 ounces of water.
	Fibercon, Metamucil, Konsyl, Serutan, Citrucel
	
Osmotics help fluids move through the colon	Sorbitol, Miralax, Cephulac
	
Saline laxatives act like a sponge to draw water into the colon for easier passage of stool.  Use cautiously in individuals with renal insufficiency
	Milk of magnesia	
Lazy bowel syndrome may occur if laxatives are used frequently, causing an individual to become dependent on them for proper function. Laxative use can also lead to other problems, including poor absorption of vitamins and other nutrients and damage to your intestinal tract.  Use cautiously.
Staff training is essential in preventing constipation.  Staff need to be trained on:
•	Recognizing symptoms 
•	Individualized bowel patterns
•	Normal/abnormal bowels (using the Bristol Scale see below)
•	Individualized protocols (if applicable)
Where and to whom does this apply?
•	This protocol applies to anyone supported by DDS who experiences constipation
•	Information regarding the individual’s status relative to this issue is to be handled in the same manner as any medical information according to HIPAA regulations.

Where can I find additional help?
•	DDS – Health and Wellness Promotion: www.mass.gov/dds